Comparison of staged thoracoscopy and median sternotomy for lung volume reduction.

BACKGROUND: Lung volume reduction operations have proved beneficial for emphysematous patients, but questions remain about the role of a unilateral procedure. METHODS: Fifty patients were prospectively enrolled in a lung volume reduction surgery program for emphysema with staged unilateral video-assisted thoracoscopic procedures (VATS group). These patients were compared with 29 patients having bilateral lung volume reduction procedures by median sternotomy. RESULTS: The VATS group was slightly older and had shorter 6-minute walk distances, but otherwise the two groups were similar. Hospital stays were shorter for each unilateral VATS procedure, but the total of the two hospital stays was longer than the stay for the sternotomy group (21.1 versus 14.8 days). Complications were comparable, there were no in-hospital deaths, and there was significant difference in the 1-year mortality rate (VATS, 6% versus sternotomy, 13.8%; p = 0.137). Functional test results were comparable between the groups with improvements in percent predicted forced expiratory volume in 1 second (VATS, 41%, and sternotomy, 40%), 6-minute walk distances (VATS, 48%, and sternotomy, 26%), dyspnea scores, and acid base measurements. CONCLUSIONS: Staged lung volume reduction operations do not appear to offer any measurable advantages over a single hospitalization and bilateral lung volume reduction procedures.

Effect of bovine pericardial strips on air leak after stapled pulmonary resection.

BACKGROUND: Surgical procedures for emphysema have been proposed and in many settings resulted in significant improvement in dyspnea and function. The most prevalent surgical problem in all series is prolonged postoperative air leak. METHODS: One hundred twenty-three patients undergoing stapled thoracoscopic unilateral lung volume reduction operation were prospectively randomized to receive either no buttressing of their staple lines or buttressing of all staple lines with bovine pericardial strips. RESULTS: The two groups were comparable in preoperative risks and in the severity of their emphysema. Postoperative complications were identical in the two groups with respect to pneumonia, empyema, and wound infection; however, there was a significant difference in the duration of postoperative air leaks. Those having the pericardial strips used to buttress their staple lines had chest tubes removed 2.5 days sooner and were discharged from the hospital 2.8 days sooner as a result. The cost data revealed that because of the cost of the pericardial sleeves, the overall hospital charges were almost identical for the two groups ($22,108 bovine, $22,060 no bovine) in spite of the shortened hospital stay. CONCLUSIONS: The use of bovine pericardial sleeves to buttress the staple lines in thoracoscopic unilateral lung volume reduction operation results in a shorter duration of postoperative air leaks. Total hospital charges were comparable in the two groups as the 2.8 days saved in the hospital were offset by the cost of the pericardial sleeves.

Validity of simple approach to scoring and standard setting for standardized-patient cases in an examination of clinical competence.

The results are disappointing, providing little support for the validity of the case-passing decisions based on this simple approach to scoring and standard setting. The case-passing decisions predicted what the case author intended for about only 73% or 74% of the students on average and, with agreement expected by chance removed, predicted what the case author intended for about only 25% of the students. Even with the use of the optimal pass/fail cutoffs and the dropping of students with ambiguous borderline global ratings, the case-passing decisions failed to agree with the case authors' global ratings for 15% to 30% of the students. The findings might be dismissed as simply due to low reliabilities of passing decisions and global ratings based on a single case. Although this concern would apply to intercase reliabilities, which would be subject to case specificity, the appropriate reliabilities here would seem to be intracase (i.e., intrarater), which should be fairly high (if they could be computed). Nevertheless, it seems reasonable to expect much better agreement between results of case scoring and of standard setting developed by the case author and the case author's global ratings of performance on that case, given that the case author might recall the checklist, assign a weight to each item, and so forth. Also, case-passing decisions would possibly agree more with global ratings of live or videotaped performances than with ratings of written summaries of performance; however, that question remains a challenge for further research. In conclusion, the study provides only weak evidence, at best, for the validity of the scoring and standard setting commonly used with SP assessment. The results do not undermine claims about the realism of the SP approach, however, nor do they call into question the standardization afforded by this method of assessing clinical competence. The results do raise serious concerns about this simple approach to scoring and standard setting for SP-based assessments and suggest that we should focus more on the observation and evaluation of actual student performance on SP cases in the development of valid scoring and standard setting.

Benefits associated with a respiratory care assessment-treatment program: results of a pilot study.

BACKGROUND: During the months of July, August, and September 1993, we implemented a respiratory care assessment-treatment pilot study on the orthopedic surgery floor in our hospital. The purpose of the study was to determine feasibility and establish cost-effective treatment plans with quality patient outcomes, while maintaining appropriate communications with physicians and nursing staff. STUDY DEVELOPMENT & IMPLEMENTATION: The study's Task Force developed protocols for oxygen therapy, aerosolized medication therapy, volume expansion therapy, and bronchial hygiene therapy using the American Association for Respiratory Care's Clinical Practice Guidelines as supporting documents. Meetings were held with the orthopedic surgeons and nursing staff to inform them of the key components of the pilot program. Ten patient evaluators were trained to assess patients and implement treatment plans. EVALUATION METHODS: A reference book was established that contained the protocols and support material. Patient outcomes were evaluated using previously established quality assurance plans. The length of stay, procedural volume, and cost data were collected. EVALUATION RESULTS: More than 50% of the orders received during the pilot program were for "Respiratory Care Protocol." This allowed the patient care evaluator the flexibility to initiate one of the approved protocols if indicated. No changes in patient outcomes were noted and average length of stay remained unchanged during the pilot study compared to the base period. Treatment volumes decreased, resulting in identified cost savings of $5,318 during the study. Nurses and physicians supported protocol implementation, and increased communication among caregivers was documented. We believe that professionalism of the RCPs was enhanced without compromising the ultimate decision-making responsibilities of the physician. CONCLUSIONS: The use of respiratory care protocols is an acceptable method of developing clinically effective and fiscally responsible care plans. RCPs at our hospital were able to implement care plans that resulted in cost savings without a measured change in patient outcomes. Approval has been extended from the Executive Committee of the medical staff to expand hospital-wide.

Absence of left anterior descending coronary artery associated with anomalous origin of left circumflex coronary artery from the right coronary artery: a case report and review.

In this report we present a case of a 30-year-old female patient with a single coronary artery, which consisted of a right coronary artery from which there was an anomalous origin of the left circumflex coronary artery. There was no left anterior descending coronary artery. The clinical and other noninvasive diagnostic features of this rare angiographic variant are described and compared to other known varieties of coronary anomalies. The absence of objective evidence of ischemia or left ventricular functional impairment and analysis of the angiographic data suggest that this is another benign variant of coronary anatomy.

Sleep-disordered breathing and poor functional outcome after stroke.

BACKGROUND AND PURPOSE: We objectively evaluated patients with recent stroke to determine the prevalence of sleep-disordered breathing (SDB) and whether SDB was associated with unfavorable clinical outcomes. METHODS: Forty-seven patients with recent ischemic stroke (median, 13 days) were studied with computerized overnight oximetry for evidence of arterial oxyhemoglobin desaturation (SaO2). Polysomnography was also performed on 19 patients. Medical history, sleep history, location of stroke, and severity of neurological deficit were recorded, and patients were observed by staff for evidence of snoring and excessive daytime sleepiness. Functional abilities were measured with the use of the Barthel Index (BI). Outcome variables included ability to return home at discharge, continued residence at home at 3 and 12 months, BI at discharge, BI at 3 and 12 months, and death from any cause at 12 months. RESULTS: Mean SaO2 during oximetry was 94.0 +/- 1.7%, and percentage of recording time spent at < 90% SaO2 was 4.3 +/- 5.7%. The number of desaturation events per hour of recording time (desaturation index [DI]) was 9.5 +/- 9.67, with 15 of 47 (32%) having DI > 10 and 6 of 47 (13%) having DI > 20. Oximetry measures of SDB correlated with lower BI scores at discharge and lower BI at 3- and 12-month follow-ups (P < or = .05, Pearson coefficients). Oximetry measures correlated with return home after discharge, but the association between oximetry measures and living at home was lost at 12 months. Two oximetry variables correlated with death at 1 year. Brain stem location correlated with higher DI and time at < 90% SaO2, but patients with hemispheric stroke and oximetry abnormalities also had worse functional outcome. No correlation was found between oximetry values and sex, age, preexisting medical conditions (except previous stroke), or severity of neurological deficit. Oximetry abnormalities were associated with a history of snoring. Polysomnography on 19 patients confirmed oximetry evidence of severe SDB. Eighteen of 19 patients (95%) had an apnea-hypopnea index (AHI) of > 10 events per hour of recording, 13 of 19 (68%) had an AHI > 20, and 10 of 19 (53%) had an AHI > 30. Desaturation events were largely due to obstructive apneas. CONCLUSIONS: SDB accompanied by arterial oxyhemoglobin desaturation is common in patients undergoing rehabilitation after stroke and is associated with higher mortality at 1 year and lower BI scores at discharge and at 3 and 12 months after stroke. SDB may be an independent predictor of worse functional outcome. Obstructive sleep apnea appeared to be the most common form of SDB, and the frequent history of snoring suggests that SDB preceded the stroke in most patients.